HomeMy WebLinkAbout1301A WORKERS'<OMPENSASIONDECURAiION APPLICATION FOR PLUMBING PERMIT J �
� I he�eby affirm that I hove o ce�Nflca�e o oroe���o celf �f,qyy�q
�nwro,a o�ertifiw�e o1 Worke�i Cpmpe ti �qSWo�ce, CE 817(RkY.10�81)
o.a ce�hfipd copy�he�eoi(Sec.3HQ0,ta GOUNTY OF LOS ANGELES BUILDING ANDSAFETY
�cY Na. (omppny
<OrtUiad copY b h�reb�furnished
coa 4onKnr+r ro rni u+r,wmr ox r��I n���ss �
� Camf�ed copy is filed�.�rh fia co�niy bu�ldrtp�ns _
lion depertmenf. NUMBER flI(iURC OR tTEM � fEE
LOFAtI�Y
�t . �" r��P�,�� ` � WAiERClfJSET
f.�EA
CERTIF7fATE OF N FROM WORRERS' BAtn iUB Si.
(�OMPEN TION IN$URANCE ��p OWN�R
{Th1f�sKttoerwd eoT 6�eompbf�d i!1k�reork invofr�d bp ��
fh�pimilt i�fpr an�handtid do0qn(f100)or I�n_I U1t�AiORV ppp�u
I cefllh�ho�in+he pe.for.rwMe a+�he work for wh�ch�h�s � �
perml�i�is�ued,I fhall np�empioy ony person�n a��mamror SNK frtv iEl NO ,
so m�b becolne wbjecl Io r{ro Wprkprs'Compenwlion lawe. p���.R . .
�CON(RACTOp
DaTh APPlicuni cLOIliES WAShIFR '
NOTIGE �O APPl1�ANi: if, aher mo4�ny�h�s Cm�ifico�a o{ ��� � j
fxert�7tion, you sho�ld be4ome wbjec< to �he Wohen' SWiMn��NGVOOtRECEvtOrt
Cqmpen�lian prowsioee o£11�e Labpr Code,�ou mua�forth� �AWN SPRINKIER SYSIEM CIiY r�i.No.y y,?•jp) ,
w�th Wm{�ly wiih wch pq�iaom vr �hK ps�.���ahail M Si`��� , t�� � • .
deCmpd.e�oked. WArFA MfATEa
U�NSE�CA�`1tRACTORS DECL4RAiIQN - U47RK7 NO. Bv ;
I hap�}y cftjrm Aq�I qm licarq4d wdx pro.:sio,g offhaPrer 9 fi�5 Sv5lEM pur�rs � .
Iccmm4nr,i�g w�if,Sea�on 70001 0�4�risio�3 d Ihe Bu�i�s OU7�EiS O�FR �� .
and P�fessibns Cpde,rnd my hcense 4 m full f�and eMx+. S aEP SvSteh� f1NAL� � �
pR� VALIDATION O ;
Licln7eNumber l� aSs� � �� OC :
Flf}Al O ;
�_ .
colmeero. oote Z eY W .
� I am e.emp� m Sec A
� B-BP.C.fa Ihis reawn � . i i
�! Plan check fee
� �e' PIUMHING PERMIT ISSIStNG iEE S ��1 3�,1 q i
Signawe 1• • • • •:;
TOTAt FEE
� vlpn cbeck opplkant I � � � �;J l;- .
SINGLE FqINILY
HOME OWNfR-BUILOER 0'KIARATION Nome ' I h���';;
I heTM aK�rm�Ya��a^i e.empt hom the Co.�eacra's Ucense ��
Lnw fp M�e follow�ng rcoson(Sec�ion 7031.5,6os7neas and � ��.:ri—O�l
Rofeaiom Code): Ciry Tel.No.
❑ I,as owner o(ihe o � 'll do�he work and eha �
C� Oer Y•w" .
srtucfyro is nW�nM�ad a aHaed for wle�Sec+�on ► ,
70de,9�s:n�ys ard RoFesa�ons Code).
CONSTRUC110N LENDING AGENCY �
I hereby aifirm rhor ihero�s a cons�ruNion le.�d��g ogenty tor
�he parlormonce of d+e wor4 for which th�s pe.mi�i:lisued .
ISet.3D97,Civ.C.).
Lendar i Noma �
Lenda's AQd�ess
I cernfy tho�I houa reod thfs opppw�ion and smro iho��he � .
a6ove in4amat�on is correcl.I pyroe b comp�y with oll Cou��y ,
ordirwncps o�d SM�e low�regulaling Wumbing,and hereby
aut6wize rep�esenlurives o1 this Counly+o en�er upon fhe �
obore- i�oned�erty�Wec�ion Gu.posm. �
p SEE REVERSE FOR EXPLANATORY LANGUAGE
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